Driver rehabilitation: A systematic review of the types and effectiveness of interventions used by occupational therapists to improve on-road fitness-to-drive

1. Drivers Rehabilitation-
Journal review
-Dr Krishna N.S Mot.,Hand Splinting.,Cert In DRS

2. Title
 Driver rehabilitation: A systematic review of the types and
effectiveness of interventions used by occupational
therapists to improve on-road fitness-to-drive

3. Authors/Year of Publication
 Carolyn A.Unsworth , Anne Baker
 Faculty of Health Sciences, La Trobe
University, Melbourne Australia
 Department of Rehabilitation, School of
Health Sciences, Jonponkong University ,
Sweden
 Year of publication : 2014

4. Overview
 Driver rehabilitation has the potential to improve on-road safety and is
commonly recommended to clients.
 The aim of this systematic review was to identify what intervention
approaches are used by occupational therapists as part of driver
rehabilitation programmes, and to determine the effectiveness of these
interventions.

5.  Method: 6 electronic databases were refined and
searched
 Quality of studies was assessed using the Downs and
Black Instrument
 16 Sixteen studies were included in this study
 Three types of intervention approaches are commonly
reported,
 However, there is limited evidence to determine to
effectiveness of these in improving fitness-to-drive

6. Keywords
 Driver intervention
 Driver rehabilitation
 Fitness-to-drive
 On-road
 Systematic review

7. Introduction
 It has been well established in the literature that driving a
car is a meaningful and important activity
 Driving allows people to access the world around them.
This may include simple and everyday tasks
 Driving is closely associated with the concepts of
mobility, independence, and sense of security (Keskinen,
1996; Michon, 1985),

8.  The World Health Organizations classification of function
(WHO,2001) as a framework.
 Internationally, occupational therapists are often the
health professionals who are trained, and thus invited to
undertake fitness-to-drive assessments
 Occupational therapists have unique skills in the analysis
of task performance and the retraining of activities of
daily living, and therefore play a key role in this area

9.  The first step in fitness-to-drive assessment involves
evaluation by a medical practitioner who ensures that the
person meets the appropriate medical standards for
driving

10. Step 1
• Fitness to drive assessment by Medical practitioner
• Fitness to drive by occupational therapist
Step 2
• Fitness to drive assessment by CDR’s
• Comprehensive driver evaluation
• Both On and Off road assessment
Step 3
• Comprehensive driver evaluation
• Both On and Off road assessment

11. PROCESS
CDR’s
Top Down
approach
Bottom up
approach
(Remedial
practice)
Training
program
On road
practice/Of road
practice
From
Therapis
t
From Patient
to Therapist

13. Aim of the study
AIM 1
• To identify what types of interventions are used by occupational
therapists as part of driver rehabilitation programmes to improve
on-road fitness-to-drive
AIM 2
• To identify what types of interventions are used by occupational
therapists as part of driver rehabilitation programmes to improve
off-road fitness-to-drive

14. Materials and Methods
Step 1
• Search strategy
• Methodology
Step 2
• Inclusion criteria
• Exclusion criteria
Step 3
• Population
• Intervention
• Outcome
• Result analysis

15. Search Strategy
 The electronic databases
 MEDLINE,
 CINAHL,
 Psych Info,
 Embase Libarary,
 The Cochrane Library, and
 OTD Base were searched from inception to December 19th,
2012, using the terms Rehab AND Fitness to drive OR
Automobile Drive.

16. Inclusion criteria
 Single case studies were included.
 Studies had to be published in English in a peer reviewed
journal.
 Narrative reviews, conference proceedings, and non full-
text studies were excluded.
 Systematic reviews related to a similar topic were
excluded unless all of the studies that were included in
the original systematic review also meet the inclusion
criteria for this systematic review.

17. Population
 Participants in the study had to hold or have previously
held a full drivers license
 Drivers of these vehicles may be required to undertake a
driver rehabilitation programme using similar techniques
to those described in this paper, the type and duration of
intervention

18. Intervention
 These participants are administered by OTDA
 OTDA’s are specially trained occupational therapists, who
have completed an intensive post-graduate training
qualification.
 They are able to administer a range of driver
interventions, including computer-based driving
simulator training, off-road skill-specific training, off-road
education programmes, on-road training and car
adaptations/modifications.

19. OT-DORA
 OT–DORA also offers the ability to screen clients who are unsafe
to take an on-road assessment.
 Done easily in a clinical setting, without driving simulators or
taking the client on-road, the OT–DORA Battery allows
practitioners to, with minimal risk and expense, find clients’
strengths and weaknesses and pinpoint areas on which to focus
during rehabilitation.
 The manual describes how the OT–DORA was developed,
summarizes research to support its use, and details instructions
on how to administer the Battery with clients.
 Sections of the assessment include—
 Initial Interview
 Medical History
 Medication Screen

20. Quality Assessment
 Quality assessment was completed independently by the
two authors using the Downs and Black Instrument
(1998).
 The Downs and Black Instrument consists of 27questions
that are grouped into four sections: ‘reporting’, ‘external
validity’, ‘internal validity (bias)’, and ‘power’.
 Combined scores from each of these four sections gives a
final score ranging from 0to 31, with a score of 31
indicating a high quality study and a score of 0 indicating
a low quality study.

21. Levels of evidence
 LOE criteria described by Centre for Evidence Based Medicine
 Using this system, evidence was graded from Level 1a
through to Level 5;
 with Level 1a offering the highest Level of evidence
 Level 5 offering the lowest Level of evidence.
 Level 1a evidence represents a systematic review which includes randomized
controlled trials (RCTs),
 Level 1b evidence represents a RCT with a narrow confidence interval,
 Level 2a evidence represents a systematic review of cohort studies,
 Level 2bevidence represents an individual cohort study,
 Level 3 evidence represents systematic reviews involving case-control studies, or
individual case control studies,
 Level 4 evidence represents case series and poor quality cohort and case-control
studies, and
 Level5 evidence represents expert opinion

23. PRISMA Guidelines
 Using PRISMA guidelines, the number of studies
identified, included and excluded from this review is
included as a flow diagram, and transparent and
complete reporting of studies is pro-vided in table
format.

25. Only for stroke

26. Results
 A total of 821 studies were identified.
 After duplicate studies were removed, 458 studies remained.
 Of these 458 studies, 16 met the inclusion criteria and were included
in the review.
 The included studies were published between 1969 and 2012.
 A range of study designs were included : case studies, cohort
studies, cross-sectional designs, pre-post tests , and RCTs.
 Quality assessment scores ranged from 5 (Match and Miller, 1969) to
31 out of 31 (Mazer et al., 2003; Roenker et al.,2003).
 Two case studies were included, that both provided only Level 4
evidence, but both were reported with sufficient quality to attain
mid-range scores of 15 (Anschutz et al., 2010) and 17 (Gamacheet al.,
2011) on the Downs and Black Instrument.

28. Secondary aim description
 Of the 4 types of intervention approaches included in this systematic review,
 two types had some evidence to support effectiveness.
 There was Level 1b evidence to support the effectiveness of off-road skill-specific
training, provided by a high quality RCT with 70 participants in addition to studies
which provided lower levels of evidence (one study with Level 2bevidence and one
study with Level 4 evidence).
 Computer-based driving simulator training was also supported by Level 1b
evidence with 32 participants.
 An off-road education programme was shown not to be effective in a Level 1b
RCT with 65 participants,
although Level 4 evidence presented by Eby et al. (2003)suggests that some education
tools may encourage older drivers to seek assessment or promote discussion about
driving and when to cease this activity.
Given the presence of only one case study(Anschutz et al., 2010), it can also be said
that there was a was alack of evidence to support the use of car
adaptations/modifications(

29. Discussion
 This systematic review identified 16 studies evaluating
intervention approaches that are used by occupational
therapists as part of driver rehabilitation programmes to
improve on-road fitness-to-drive. We found Level 1b
evidence to support off-road skill-specific training,
computer-based driving simulator training , and off-road
education programmes. There was less evidence available
to support the use of car adaptations/modifications
 Further research in this area is required as it does not
have much literature evidences

30. Limitations and
Recommendations
 Future studies, and any meta-analyses conducted, should
also take into account the diagnostic group of the
participants, severity of impairments experienced, as well as
age.
 Interventions may need to the specific characteristics of
participants with different diagnoses, or impairments, or
ages (or combinations of these).
 Hence, future research could explore the effectiveness of an
intervention (such as computer based driving simulator
training)with participants in two or more diagnostic groups
(such as stroke and acquired brain injury) with different
levels of severity (such as mild, moderate and severe), or
different ages (such below or above 40 years of age).

31. Conclusion
 Three types of intervention approaches are commonly
reported, however, there is limited evidence to determine
to effectiveness of these in improving fitness-to-drive.
 Further research is required , with clients from a range of
diagnostic groups to establish evidence-based
interventions and determine their effectiveness in
improving these clients’ on-road fitness-to-drive.